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Home My Public Portal About5505 ROSEMEAD BLVD_Building__ WORKERS COMPENSATION DECLARATION � n hereby affirm that 1 have r certificate Comp of tion int to self " APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or(at/feftdied copy thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY KIIcyGNVte 'JZ5 CoTpony BUIU)ING ❑ Certified copy is hereby furnished 0?-.2 L' Si FOR APPLICANT TO FILL IN ADDRESS / Q� ❑ Certified copy is filed with the county building Irtapec- Q tion department �j CITY CC ZIP D b LOCALITY Date ,'/ - Applicant CERTIFICATE OF EKEMPTERS'ION FR WORKSIZE OF LOT NOW OFR LOi NROIeSS CROSS ST COMPENSATION INSURA CEASSESSOR (This section need not be completed if the permit is far one TRACT SLOCK _— LOT NO MAP BOOK J PAGE w C.. PARCEL d jQ hundred dollars ($100)or less ) gyt,AR ZONE MAPINO I certify that in the performance of the work for which this _ permit is issued, I shall not employ any person in any manner ADDRESS NDCODIIITIONS so as to become subject to the Workers'Compensation LawsV CITY ZIP O V Date Applicant AR'OIITECTOR % 0 I UP TYPE FIRE PROCESSED Or Q NOTICE TO APPLICANT If, after making this Certificate of ENGINEER � NO ODNST ZONE t- Exemption, you should become subject to the Workers' Compensation provisions of the labor Code, you must forth- ADDRESS (',RO with comply with such provisions or this permit shall be TEl STATI5IT(71L F TION , APT CONDO deemed revoked CONTRACTOR -Z1L/ LICENSED CONTRACTORS DECLARATION ADDRESS.9-114 S 14 � !.' -�+ NO G3 G CLASS No DWELL uNlrs I hereby offem that I am licensed under provistons of ter 9 (commencing with Section 7000)of Division 3 of the Bhua Business �G�S SEWER G A0' and Professions Code,and my license a in full farce and effectCITY NO O NO CLASS CNECK BK P(. � A I�f 1 License Number L47?lo'k L Lic Class SfzE STORIES 2 FAMILIES ONE vuuA 3307 "''.,.,•'75'.7_ Controcta. C- IA9 DAYIE• Date 31191q -5 DESCRIMON OF WORK ADD NEWLJ $ � 1 ITEMS ALTER LJ I am exempt under Sec �• ► T TFL 3379.71 � B EP C for this reason TpsflG REPAIR ❑ $ (Y ��79.71 EXISTING BLDG OFMOI ❑ k REKI: USE OF ` f1I S+gnature (PRINT) (, TEL Q FINAL 3307 ?3D9.E7 OWNER UI R DECLARATION DATE -7- 23-1-T I hereby affirm that I am Vxempt from the Contractor's License ADDQFSS LIDI.]D- 12/14ii:L Law for the following reason (Section 7031 S, Business and FINAL 777 Mh �� Professions Code) By rYtf7Y,I FjyntT.'� ❑ I, as owner of the property w my employees with BUILDINGArUtFL� t,7vZ I wagm as their sale compensation,will do the work andLOCALITY (1� C CK 4309.87 the structure is not intended or offered for sale(Section ,.ef 7041, Business ns and ProfessioCode ) Dl �•�r l"v � • ❑ I,as owner of the property, am exclusively contracting CONTRACTOR NO with licensed contractors to construe the project (Sac- ADDRESS tion 70", Business and Professions Code ) pc D000-{�1 3/19/93 CONSTRUCTION LENDING AGENCY I YARD My1' TOTALI $7$E 1 PM Sl• �CI�J I hereby affirm that there a a construction lending agency for FRONT the performance of the work for which this permit is issued Pt (Sec 3097 Civ C ) SIDE PL y Lender's Name �J p ^ PC Fee Permit ' Y'a a�- LDAAA Ref • ; lender's Address e 1 certify that I have read this application and state that the71 Issuance F S66 LDMA P/C• above information is correct I agree to comply with all County Inveaigotion Tee O n 6 ry ordinances and Slate jaws relating to building construction Total Fee 7 8 / LDMA Perm and hereby authorize representatives of this County to enter '�u n the above-m t ed property for inspection purposes fEL 11t1/ERLE FOR D�LATUTOIIY LANOUAGF� Sgrimure o Applicant Agent Duie APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BIfLDNG ADDRESS _/ I hereby affirm that I have a certificate of consent to self macre BUILDING ADDRESS S r/ or a certificate of mckers Compensation Insurance or a certified 'G /� Cf jj7NO ISec�38y0�0 Lab C) ZIP-� Canroen •/ A'fiDx ✓ C�_ /1SIZE OF LOT OF BLDGS NOW ON LOT `'copy a hereby lurrusfod /�9� NEAREST CROSS ST ❑ Certified copy o filed with the County building inspection TRACT BLOCK LOT NO . department I USE DONE AVP NO Date 4'-J_9¢APP(1cZnl4 i&Z• V� ! r-,2 S, ASSESSOR AVP BOOK RAGE PARCEL 3 SPECVL CONIX710N9 CERTIFICATE OF EXEMPTION FROM WORKERS OWhWR TEL No COMPENSATION INSURANCE -< Z W7rHlN 1000 FT OF SCHOOL? YES D1O (This Section need not be completed of the Permit 0 for one hundred ADDRESS dollars (5100)or lees.) I r L DISTRICT GROUP Tv CONST FIRE ZONEXo-�� ED BY I certify that in the perlormance of the work for which this Permit Cm / LP � Q a Issued I shall not employ arty Persian in any manner so as to -e 0/ .1 _J became eub)ad t0 the Workers Compensation Leve ARCHIIECT ORE ER TEL NO SW119TICAL F�y1TgN APT CONDO Date Applicant ADDRESS CLASS NO DWELL UNITS AOTTCE TO APPLXANT If after making the CerMcate of REOUIRED TOTAL SE Exemption you should become Sub)ect to the Workers CONTRACTOR TEL NO SET BACK YARD IAYv I'AUCLNE W DI-H Compensation prowSonS of the labor Code you mus forthwith Comply with such provisions Or this permit shall be daemed revokedADIXiESS LIC NO pF LST _ •T LICENSED CONTRACTORS DECLARATION19 44 ZZ siDE "^ `' •,:4 CTTY LIC CLASS PL I hereby affirm that I snit licensed undweod erprrtal Chapter B SEWER AAP (Commencing with Section 7000)of Division 3 of the Business and SO FT SIZE NO OF STORIES NO OF FAIAUES NEW BK P(i TOTAL 1.ry7 344 Professional Code and my lcdn4a!n full force and efface /�L��I/ (- license NU/mbeL CJ1�'`L G CJ IJc Class ( •— •�` DESCRIPTION OF y�RK ADD ❑ e LDAiION COW—� CHECK 157.348 Contractor rrS'rLS: �.ic Date1-�'-� ALTER ❑ $ ❑ 1 am exempt urger Sec REPAIR ❑ $ BdPC for this reason DEMOL ❑ LDAu wC Ai/ ?/93 a Date USE OF EXISTING BLDG URM ❑ F ,�y Signature APPLICANT(PR9vT) TEL NO LOW Perm. FEL A I 9•40 Z ❑ 1 as owner of the Property or my employees With wages as = ^^^FFFy' their sole compensation volt do the work and the Structure is ADDRESS O OR not intended or offered for sale (Section 7044 Business and FINAL DATE Q I bi 0 PfOle9910n4 Code) 1MLL THE IP0.1GVli aR NMiE BlAplq OLGLPNHT NVIIXf A INZWD01191MTEPYL ff��MMfff1 y aR A I,m(TI..E LONAMIO A H.ZMDOIb VATERNL EOWL 70 pm anEATEB i11.AN THE 1.1_ ❑ I as owner contractors the property em B%e prof c C Sects tlrlg 04th AMOIARS srEm7E°ON THE HaeZAPOW9 WTENALa.FOraNAT1oN GIAIEI FINAL BY I 00 V licensed Pmteto ori Code) the protect (Section 7044 IES❑ No❑ CHECK &emesis and Rofeasons Code) J. Y11LL T1E MEMED USE OF THE Blf[ILAO BY TIE ARxCINi OA N1UlE BIIIIINO OCCti1wT{EOINE A PEMGT FOR CONSTMIaIioN OA 11001F1CJSIpN Ft H TIE SOUTH CONSTRUCTION LENDING AGENCY au�oEUH�ESouAury AvvlAaEUF+rr osmics*Iscoxml SEE FEuartwa cuECKLer FOR Uwe jl] I Ioreby affirm that there Is a construction Iendmg agency for vEs❑ Ip❑ ,w the performance of the work lar which the permit a issued(Sec SOB* cN c) a""E w"%� °w a oR"a �°�"R° E A bEa"eap: 0000-0001 b/ 3/9:r TILE 3 ONPT I30 S CTOHe] W Tq M]A CpCEP+++m IUI.eCOU3 OOEE 1 A11 9:57 Lender a Name THU 2 IS RE ORnNO 1D IFORON .TN6 RMI1 F T1E 9CId.O Lendera Address p 1.1101 W/QM I f pe that I thea read thus matin is rrre dote under penally /�� g of ertify t That the above this fo lic a correct I agree to penally PC FEE PERMIT FEE $4me all Slat laws relating to building natives of the County tSSU FEE Y far Inspection Purposes m INVESTIGATION FEE TOTAL FEE 01 / J• 6 /q /' SEE REVERSE FOR EXPLANATORY LANGUAGE•? i COUNTY OF LOS ANGELES TEMPLE CITY R 0508 - BUILDING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0910270077 PHONE (626) 285-0488 EXT LEGAL ID NO OF CONST BUILDING ADDRESS ITR 3623 LT B I SQ FT STORIES TYPE I 5505 ROSEMEAD BL 1 35 V-B TEMP CA 917801802 (ASSESSOR INFORMATION NUMBER NEAREST NEAREST CROSS STREET BROADWAY 5387-032-013 I I THOMAS PAGE 596 GRID H4 LOCALITY TEMPEL CITY Cl ITEHANT 1EXIST BLDG USE COMA USE TONE C-3 (ISSUED ON PROCESSED BY 1 EXIST OCC GRP 110/27/09 SR 1 (OWNER TEL NO SLOGS NOW ON LOT VALUATION IFI (SDA FI BY CODE 1 11780 WIND JOSEPH - I 9 300 \/� 11780 WINDSOR RD 1 1 J 99 I SMAR 911082526 1 FEES PAID IDESCRIPTIVN OF AORR 1 1 REMOVE EXISTING ROOF, INSTALL SAME 4 PLY BUILT UP 1 I IFEE DESCRIPTION QUANTITY UOM AMOUNT I I 1APPLICANT TEL NO I I I 1JOHN L SMITH (714) 267-1076- IAA BLDG PERMIT ISSUANCE 27 75 1 I 123200 MODOC CP AS STATE GREEN BLDG FEE 9300 00 VAL 1 00 SPECIAL CONDITIONS 1 PERRIS CA 92570 AC STRONG MOTION RESID 9300 00 VAL 0 93 D2 PERMIT W/O EN-HC 9300 00 VAL 216 60 TOTAL FEES 246 28 CONTRACTOR TEL NO APPROVALS DATE INSPECTOR SIGNATURE I J L SMITH ROOFS INC (714) 267-1076- 1 23200 MODOC CT LIC NO LOCATION AND SETBACKS PERRIS CA 92570 443878 C39 1 I SOILS ENGINEER APPROVAL 1 I I 1ARCHITECL OR ENGINEER TEL NO 1 1FOVNDATION/TRENCH FORMS I LIC NO 1 ISLAS/UNDER FLOOR I I IRAISBD FLOOR FRAMING 1 1MAP NO SEWER MAP BOOR PAGE FIRE TONE CMP 1 1UNDERFIOOR INSULATION 1147H265 3 001 1 I I I IFL.00R SHEATHING IND OF FAMILIES DWELLING UNITS AFT/GOND STAT CLASS I I I I NO 22 (ROOF SHEATTS 6 1 SCHOOL WITHIN HAZARDOUS ISHEAR PANELIS (AIR QUALITY 1000 FEET MATERIALS NO NO NO I IFRAME INSPECTION I I REQUIRED TOTAL SETBACK FROM EXIST I (FIRE SPRINIQLER HANGERS I SET BACK YARD HWY PROP LIM WIDTH 1FRONT PL- I (INSULATION/WEATHER STRIP SIDE PL- INTERIOR LATH/DRYWALL I I 1EXTERIOR LATH I I I I IRATED FLOOR/CEIL ASSEM 1 (RATED WALL ASSEMBLIES I RATED SHAFTS/OPENINGS I I I I I 1T-BAR CEILINGS I ILOT DRAINAGE 1REPORT ID DM261 ROUTE TO BS0508 I I I I